PRELIMINARY INFORMATION INTAKE FORM

Name _____________________________ e-mail _______________________________
Address ________________________________________________________________
________________________________________________________________________
Phone: (home) ________________________ (work)_____________________________
Employing Agency & Organization _________________________________________
Job Title ____________________________ Grade & Series _____________________
Alleged violation: Lost opportunity due to:
___________ Race ___________ Color ___________ Sex/Gender
___________ Sexual harassment (including pregnancy discrimination)
___________ National Origin ___________ Religion
___________ Age ___________ Disability ___________ Reprisal
Was denied opportunity related to:
___________ Promotion
___________ Performance appraisal (Are you under Lab Demo? Yes / No)
___________ Training opportunities
___________ Termination
___________ Reduction in grade or pay
___________ Subjected to unwarranted/illegal security investigation
___________ Other ________________________________________________
Form of discrimination:
___________ Disparate Treatment
___________ Disparate Impact
___________ Harassment
___________ Failure to Reasonably Accommodate
Have you filed an EEO complaint? ________ Yes _________No
If yes, against what agency and organization?________________________________
___________________________________ When?_____________________________
EEO Case Number(s):____________________________________________________
At what phase are you in the process? _______________________________________
_______________________________________________________________________
Please attach copy of Claim with associated
Additional Comments: ___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Mail to: Redstone Area Minority Employees Association
P.O. Box 22214
Huntsville, AL 35814-2214
ATTN: Mr. Matthew Fogg, Executive Director

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Local Contact (256) 859-2740
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Toll Free Pager Number:
1-800-532-2025